If you prefer to complete the Medical Intake Form prior to your appointment, please click the link below, print out the form and bring it with you to your scheduled appointment.clickMEDICAL INTAKE FORM

Massage Therapy Health & Wellnesswww.massagebodybenefits.com MEDICAL HISTORY QUESTIONNAIRE The purpose of this confidential form is to maximize the safety and effectiveness of your massage.Date_____________________ Referred by__________________________________________ Name_______________________________________ Date of Birth______________________Address___________________________________________ City_______________________State_____Zip Code_____________Phone (Home)__________________(cell)______ _________Email address:____________________________________In case of emergency call: ___________________________Telephone # _______________________Do you have any muscle pain, stiffness, or tension: YES ___NO­­__ Where?________________­­­­______Is there any area where you would like extra time spent? YES _____ NO ____(neck, shoulders, low back….)_____________________Do you have trouble sleeping? YES ___ NO ___ Are you pregnant? YES ___NO___ Due __________Please Indicate and List Any Medical Problems or Conditions Blood Pressure, Diabetes, Gout, Cancer other: __________________________________________ Current Medications: ______________________________________________________________ Are you pregnant? YES ____ NO ____ DUE DATE _______________________________ Do you have a Nut Allergy? YES _____ NO _____ Skin Conditions – acne, rash, allergies, skin cancer, other:____________________________________ Lymphatic condition – swollen glands, lymphoma, other: ______________________________Recent Injury – whiplash, sprain, bruise, other: _____________________________________ Circulatory condition – heart disease, varicose veins, phlebitis, arteriosclerosis, other: _____________________________________________________________________Neurological condition – sciatica, numbness/tingling, stroke, epilepsy, other: _____________________________________________________________________ Joint problems, pain or stiffness – osteoarthritis, rheumatoid arthritis: ____________________ Bone Conditions – osteoporosis, previous fractures, cancer, other:________________________ Headaches – migraines, PMS, tension, sinus, other : _________________________________ Emotional difficulties – depression, anxiety, psychotic episodes, other: ____________________ Stress : yes _____ no _____Recent surgery (type and date): _______________________________________________ Are you under a Doctor’s care? Yes _____ No _____ Phone : __________________________You have my permission to contact my health care provider(s):_________(initial)CANCELLATION & LATE POLICY:If the client cancels their appointment with less than a 24-hour notice, or does not show for an appt, a cancellation fee of 50%- up to full scheduled session fee will be paid by the client. I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscle tension. If I experience any pain, discomfort during the session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand the massage or bodywork should not e construed as a substitute for medical examination, diagnosis or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical mental illness, and nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by the client will result in immediate termination of the session, and I will be liable for payment of the scheduled session. If a client arrives late to their appointment, there will be no cost adjustment and will end at the scheduled time as to not delay the next appointment. Signature________________________________________Date____________________ Consent for a minor: By my signature below, I hereby authorize Andrea Carangelo, CMT to administer massage bodywork to my child or dependent, as they deemed necessary. Signature of Parent Guardian:_______________________________ Date: _______________________